Caring for LGBT patients: A primer

As a patient, Keith Egan, OMS IV, has seen more than one physician who was uncomfortable with his sexual orientation.

“I have, a number of times, noticed physicians avoiding certain parts of health history and avoiding taking a sexual history,” says Egan, who attends the University of New England College of Osteopathic Medicine (UNECOM) in Biddeford, Maine, and is gay. “They avoided asking whether I was in a relationship and how that relationship was affecting my life.”

Carter Marshall, a graphic designer who is transgender, says he’s had physicians insist on using the wrong gender pronoun when referring to him, even after being corrected. An endocrinologist once told him, “I’ve never treated transgender patients, and I don’t know anything about transgender hormone management,” Marshall says.

“It’s important to learn interviewing and communication skills that help create a supportive and affirming environment. Learn how to ask questions in a nonjudgmental way.”Dr. Ng

Egan and Marshall aren’t alone. Henry Ng, MD, MPH, is the clinical director of LGBT health services at MetroHealth Medical Center in Cleveland, where he runs the Pride Clinic, which focuses on serving lesbian, gay, bisexual and transgender (LGBT) patients. Dr. Ng says he has patients who visit him from other states because they can’t find appropriate care where they live.

Some of the health issues affecting the LGBT population include increased rates of smoking, substance abuse, psychiatric disorders and suicide, according to the U.S. Department of Health and Human Services. Many physicians don’t take sexual histories of their patients or inquire about sexual orientation, according to a study in the March issue of AIDS, Patient Care and STDs.

Physicians likely have more LGBT patients than they realize, notes Dr. Ng, who is also the president of GLMA: Health Professionals Advancing Equality. Nationally, 3.5% of the population identifies as LGBT, according to the Williams Institute. But about 20% of Americans are attracted to their own gender, a recent National Bureau of Economic Research survey found.

The U.S. LGBT population has historically had a tenuous relationship with the medical establishment. Homosexuality was listed as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders until 1973. More than half of lesbian, gay and bisexual respondents to a 2010 survey said they experienced discrimination when seeking or receiving health care. More than a quarter of transgender respondents said they were denied care.

The AOA’s code of ethics states that physicians should not refuse care to patients because of their sexual orientation or gender identity.

LGBT individuals in the U.S. have gained significant acceptance, prominence and visibility in the past 20 years. Since 2003, 17 states and Washington, D.C., have legalized same-sex marriage. Several openly gay politicians currently serve in Congress. Still, to adequately treat LGBT patients, physicians must understand this population both clinically and culturally, Dr. Ng says, and not enough do.

“There are too few health professionals who are trained in LGBT health care,” he says. “And you cannot rely on physicians and medical students who are lesbian, gay, bisexual or transgender themselves to deliver all that care.”

Not all medical schools cover LGBT-related content in their curriculum. U.S. medical schools devote a median of five hours of curriculum to LGBT health concerns, according to a 2011 JAMAstudy of DO and MD schools. Some schools don’t spend any time on LGBT issues, and among those that do, the quality varies widely, the study’s authors noted.

Learn more about LGBT health

For more detailed information on treating LGBT patients, check out the following resources.

Of 33 osteopathic medical schools surveyed by the American Association of Colleges of Osteopathic Medicine this academic year, 23 require students to learn about LGBT health care in a classroom or clinical setting and 13 provide elective access to LGBT health education. Seven schools have no designated coverage of LGBT health.

UNECOM had no designated LGBT training when Egan started there in 2010. He and some fellow students persuaded the administration to introduce a four-hour mandatory seminar for first-year students on LGBT health issues. The seminar has since been extended, and UNECOM first-years now spend an entire day on LGBT health.

“It’s really important for medical students to start thinking about the diversity within the patient population that they’re going to work with and how the diversity of experiences of those patients is going to affect their health,” Egan says. “It’s important to talk about the health disparities within the different communities and to have discussions on why those disparities exist.”

Students at the Edward Via College of Osteopathic Medicine–Virginia Campus in Blacksburg receive some training in working with LGBT patients, but Sean Tai, OMS IV, thought they would benefit from learning more. He and his classmates organized an all-day community symposium in 2012 to help bridge the gaps. The symposium, which was open to the public and students of other local medical professional schools, featured panel discussions with LGBT patients and health care professionals.

Tai says the symposium taught him that LGBT health encompasses much more than he initially realized.

Clinical competence

“We often talk about the increased risk of HIV and other STDs within the gay male population,” Tai says. “We don’t talk a whole lot more about how to approach health issues with lesbians. We don’t talk about a lot of the health issues surrounding being transgender. The LGBT community is as diverse as any other community.”

While the various LGBT populations have some commonalities in health, major differences exist between the groups. Following are some of the specific health issues that can affect lesbians and bisexual women, gay and bisexual men, and transgender patients.

“From the minute I signed in, the staff actively wanted to know what I needed them to call me. And it didn’t matter what my documents said, it didn’t matter what I looked like.”Marshall

Lesbian and bisexual women are more likely to smoke, be obese and underutilize health care than straight women, according to GLMA’s Guidelines for Care of Lesbian, Gay, Bisexual and Transgender Patients. They still need to receive Pap smears and mammograms, though some may try to avoid these screenings. Some lesbians have children; physicians shouldn’t assume lesbians have never been pregnant or have no intention of becoming pregnant.

Gay and bisexual men are also more likely to smoke and underutilize health care than straight men, GLMA’s guidelines state. In addition, they are at greater risk for contracting HIV and hepatitis and more likely to have body image issues and eating disorders. Men who have anal intercourse have an increased risk for anal cancer, and some health care professionals recommend anal Pap smears.

Transgender people are more likely to face discrimination when seeking employment and health care, according to the National Center for Transgender Equality. Transgender patients may have taken black-market hormones because many insurance plans don’t cover hormone therapy and patients may not be able to afford to visit a physician. Hormone therapy may reduce fertility, according to the Center of Excellence for Transgender Health. Male-to-female patients will still need to be screened for prostate cancer and female-to-male patients may need to be screened for breast cancer and cervical cancer.

When Dr. Ng started the Pride Clinic, he found himself treating more transgender patients than he ever had. He expanded his knowledge on properly treating them by attending conferences and seeking the counsel of a local endocrinologist.

“There may be people in your own community who have these skills and can help you,” he says.

Cultural competence

In addition to understanding the unique health needs of the LGBT population, physicians can take steps to ensure their LGBT patients feel comfortable in their offices and during appointments, Dr. Ng says.

“It’s important to learn interviewing and communication skills that help create a supportive and affirming environment,” he says. “Learn how to ask questions in a nonjudgmental way. Use language the way the patient uses language.”

For instance, physicians may encounter men who have sex with men but don’t consider themselves gay.

“If you use language that is labeling—if you use words such as gay sex or homosexuals—then you might turn some people away,” Dr. Ng says.

Be aware that LGBT patients span all demographics, Tai says.

“LGBT people are everywhere,” he says. “They are going to be in cities, they are going to be in rural southwest Virginia. They are going to be wherever you are.”

Whether they realize it, physicians play a vital role in the health of their transgender patients, says Christine N. McGinn, DO, a plastic surgeon who founded the Papillon Gender Wellness Center in New Hope, Pa., which provides surgery and other health care services to transgender patients.

“If you have the type of office that’s not welcoming to transgender patients and they don’t feel like they can talk about it, then a lot of times, they are not going to want to talk about anything,” says Dr. McGinn, who is transgender. “They may never go see a doctor again.”

Dr. McGinn stresses the importance of using the patient’s preferred name and gender pronoun and recommends including a space on the intake form where patients can write their preferred name. She also suggests physicians include a pamphlet about transgender health in the waiting area so patients know the practice is aware of transgender health issues.

GLMA’s guide proposes doing this as well, and suggests displaying an LGBT-friendly symbol in the office such as a rainbow sticker.

Practices and hospitals can also register to be listed in the Human Rights Campaign’s Healthcare Equality Index. To be recognized by the index as a leader in LGBT health care equality, institutions must list sexual orientation and gender identity in their patient and employment nondiscrimination policies, have an equal visitation policy (if applicable), and train staff in LGBT patient care.

“LGBT people are everywhere. They are going to be in cities, they are going to be in rural southwest Virginia.”Tai

Marshall, the graphic designer, has seen Dr. Ng at the Pride Clinic and says it’s a night-and-day difference from some of the other physicians’ offices he’s visited.

“When you walk in the door and you sign in, they hand you papers to fill out, which ask you questions such as ‘What name would you like to be called?’ and ‘Which gender pronoun should we use?’ ” he says. “I never experienced that before. From the minute I signed in, the staff actively wanted to know what I needed them to call me. And it didn’t matter what my documents said, it didn’t matter what I looked like.”

Dr. McGinn notes that transgender patients are not necessarily looking for special attention, but that many are wary of health care professionals because of prior experiences.

“There’s a long history of the medical establishment discriminating against them,” she says.

Well-meaning physicians may not see themselves as discriminatory, but may miss vital health information about patients by neglecting to conduct an accurate sexual history of their patients. All physicians should take sexual histories of their patients and learn their sexual orientation, says Sonia Rivera-Martinez, DO, the chair of the AOA’s Council on Women, Men and LGBTQ (Lesbian, Gay, Bisexual, Transgender and Questioning) Health Issues.

“I ask patients, ‘Who do you have sex with? Men? Women? Or both? Is there anything else you want to state?’ ” says Dr. Rivera-Martinez, who is an assistant professor of family medicine at the New York Institute of Technology College of Osteopathic Medicine in Old Westbury. “And I let them know that this is a question I ask everybody.”

Tai notes that sexual orientation and sexual practices fall under the osteopathic principal of treating the whole patient.

“Osteopathic physicians focus on the idea of listening to people’s stories and learning about their experiences,” he says. “People who are sexual minorities and gender minorities have fascinating, awesome stories to tell. It’s always important to hear those stories. Once we get to know them, we can treat our patients better.”